Recurrent episodes of HE are associated with increased health care burden, poor prognosis, and risk of death. Common precipitating factors of episodes of HE include GI bleeding, Sepsis, Azotemia, Constipation, CNS-Active Drugs and High Protein Load. We report a case of Hepatic Encephalopathy recurrence following constipation. Patient responded well to combination therapy of Rifaximin and Lactulose.
47-year-old female patient, chronic alcoholic for 20 yrs, known case of Decompensated Chronic Liver Disease (CLD – Child Pugh B) with Grade II Esopahageal Varices who had undergone band ligation 4 months back presented to Emergency Department with history of drowsiness for 12 hours associated with difficulty waking up, slurring of speech and confusion.
There was also history of yellowish discoloration of skin progressively increasing over last 3 days. Patient also had swelling of bilateral lower limbs and abdominal distension since last 1 year.
No history of epistaxis, vomiting, black discoloration of stool, shortness of breath, chest pain, palpitation, orthopnea. No history of loss of consciousness, abnormal body movement, urine or stool incontinence.
There was history of not passing stool since last 4 days. Urine was not passed since one day.
She was admitted for similar presentation twice one month ago and was diagnosed and managed on the line of Hepatic Encephalopathy.
At the time of admission, she was ill looking, disoriented and confused. Her Glasgow Coma Scale (GCS) was 14/15 ( E4V4M6). Patient was Icteric and Bilateral Pedal Pitting Edema was present. Vitals were stable. Chest and CVS examination was normal. Examination of abdomen reveled distended abdomen with everted umbilicus. Shifting dullness was present. Fluid thrill was absent.
Initial lab investigations sent from Emergency department revealed altered Liver Function Tests. Total and Direct Bilirubin were elevated to serum level of 9.5 mg/dl and 5 mg/dl repectively. Prothrombin time (PT) was prolonged by 6 seconds. INR was 1.46. Liver enzymes SGOT and SGPT were 80 and 184 IU/L respectively. ALP was 596 IU/L. No fluid was obtained on USG guided ascitic tapping.
She was admitted on Medical Intensive Care Unit (MICU) for observation and was managed conservatively with following medications:
- Injection DNS with optineuron III pint IV over 24 hours
- Injection CEFOTAXIME 1gm IV 12 hourly
- Syrup Lactulose 30ml Per Oral every hourly until diarrhoea then 6 hourly
- Tablet Rifaximin 550mg Per Oral 8 hourly
- Injection PANTOPRAZOLE 40mg IV once a day
- Tablet Torsemide 10 mg PO once a day
- Tablet Spironolactone 100mg PO once a day
- Tablet Propranolol 10mg PO twice a day
Patient condition improved over 24 hours. Her PT decreased by 2 seconds and INR decreased by 0.12. She was shifted to General Ward after 36 hours with oral medications. She was discharged next day with Syrup Lactulose, Oral Diuretics, Antacids and Beta Blocker (Tab PROPRANOLOL 10mg PO twice a day). She was advised high fibre diet (to avoid constipation) , fluid restriction to less than 1.5 litres per day and low salt diet. (i.e <2 gm/day). Patient came for a follow up on OPD after 15 days and had no fresh issues.
- Prevention of Hepatic Encephalopathy Recurrence, Clinical Liver Disease, Vol 5, No 3, March 2015
- Clinical Consequences of Liver Disease, Zakim and Boyer’s Hepatology- 5th Edition